History

Fact Explanation
Period of amenorrhoea [4] [5] [6] [8] Usually this disease variety arises from pregnancy so the patient may complain of period of amenorrhoea.[4] [5] [6] [8]
Abdominal distension incompatible with period of amenorrhea [4] [5] [6] [8] The uterine distension by the tumour results in an enlargement of the abdomen to a greater extent than which would be expected for the period of amenorrhoea. [4] [5] [6] [8]
Per vaginal bleeding either scanty bleeding or passage of grape like vesicles [4] [5] [6] [8] Patient might complain passage of grape like vesicles which are tumour products or slight altered blood discharge. [4] [5] [6] [8]
Severe nausea and vomiting [7] Because of the high hCG level in the blood, there will be clinical features of Hyperemesis gravidarum with severe nausea and vomiting. [7]
Ankle swelling, facial swelling and headache [3] GTD is associated with pregnancy induced hypertension (PIH) and features of PIH such as ankle swelling, facial swelling and headache can occur [3]
heat intolerance, insomnia, anxiety, enlargement of the neck [1] Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor. [1]
Dyspnoea, Cough, Hemoptysis [4] [5] [6] [8] Pulmonary metastasis can occur and features of lung involvement with dyspnoea, cough, hemoptysis are seen [4] [5] [6]
Altered level of consciousness, headache, personality changes, seizures [4] [5] [6] [8] Metastasis to brain cause these [4] [5] [6]
Abdominal pain [4] [5] [6] [8] Abdominal metastasis can cause bleeding in to the peritoneal cavity and pain [4] [5] [6]
Haematuria [2] Renal metastasis can cause macroscopic hematuria [2]
References
  1. WALKINGTON L, WEBSTER J, HANCOCK BW, EVERARD J, COLEMAN RE. Hyperthyroidism and human chorionic gonadotrophin production in gestational trophoblastic disease Br J Cancer [online] 2011 May 24, 104(11):1665-1669 [viewed 23 August 2014] Available from: doi:10.1038/bjc.2011.139
  2. RUENGKHACHORN IRENE, PHITHAKWATCHARA NISARAT, CHATCHOTIKAWONG USANEE. Macroscopic hematuria as a presentation of gestational trophoblastic neoplasia in an adolescent woman. Health [online] 2013 December, 05(07):35-38 [viewed 23 August 2014] Available from: doi:10.4236/health.2013.57A4005
  3. DULEY L.. Pre-eclampsia and the hypertensive disorders of pregnancy. British Medical Bulletin [online] 2003 December, 67(1):161-176 [viewed 23 August 2014] Available from: doi:10.1093/bmb/ldg005
  4. REID A., HEYWORTH J., DE KLERK N., MUSK A.W.. Asbestos Exposure and Gestational Trophoblastic Disease: A Hypothesis. Cancer Epidemiology Biomarkers & Prevention [online] December, 18(11):2895-2898 [viewed 23 August 2014] Available from: doi:10.1158/1055-9965.EPI-09-0731
  5. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  6. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2010.31.0151
  7. KUSCU N K. Hyperemesis gravidarum: current concepts and management. [online] 2002 February, 78(916):76-79 [viewed 23 August 2014] Available from: doi:10.1136/pmj.78.916.76
  8. YüRüYEN MEHMET, YILDIZ OZCAN, PAPILA CIGDEM, TUZUNER NUKHET. Gestational choriocarcinoma diagnosed with spontaneous splenic rupture after pregnancy induced by in vitro fertilization: a case report. Array [online] 2009 December [viewed 23 August 2014] Available from: doi:10.1186/1757-1626-2-7518
  9. BALAGOPAL PG, PANDEY MANOJ, CHANDRAMOHAN K, SOMANATHAN THARA, KUMAR ASHWIN. . World J Surg Onc [online] 2003 December [viewed 05 September 2014] Available from: doi:10.1186/1477-7819-1-4

Examination

Fact Explanation
Symphysio-fundal height larger than dates [2] [3] [6] [7] [8] Usually the disease follows a normal pregnancy and the patient may present with a period of amenorrhoea and with enlarged uterus which is larger than the period of amenorrhoea. [2] [3] [6] [7] [8]
Nodules in the vulva and vagina [9] Metastasis to vulva and vagina may cause these highly vascular blue-black nodules [9]
Abdominal tenderness [1] [2] [3] [6] [7] [8] Metastases to liver or gastrointestinal tract may produce abdominal pain. [1] [2] [3] [6] [7] [8]
Abdominal guarding, rigidity [10] Hemoperitneum can occur due to rupture of abdominal metastasis. [10]
Jaundice [1] [2] [3] [6] [7] [8] May be present if liver metastasis causes biliary obstruction. [1] [2] [3] [6] [7] [8]
Altered level of consciousness and focal neurological deficits [1] [2] [3] [6] [7] [8] Brain metastasis cause focal neurologocal deficits depending on the location of brain metastasis and altered level of consciousness [1] [2] [3] [6] [7] [8]
Dullness on percussion, reduced breath sounds on respiratory system examination [1] [2] [3] [6] [7] [8] Pulmonary metastasis may cause canon ball metastasis and these lung signs can occur. [1] [2] [3] [6] [7] [8]
High blood pressure [5] Pregnancy induced hypertension is associated with GTD and elevated blood pressure in the first trimester may be seen [5]
Pallor [1] [2] [3] [6] [7] Profuse bleeding may be sever enough to cause anemia hence pallor. [1] [2] [3] [6] [7]
Goitre, tremor, lid lag and retraction and signs of hyperthyroidism [4] Hyperthyroidism is associated with GTD. This is thought to occur due to molecular mimicry between human chorionic gonadotrophin (HCG) and thyroid-stimulating hormone (TSH), and hence cross-reactivity with the TSH receptor. [4]
References
  1. REID A., HEYWORTH J., DE KLERK N., MUSK A.W.. Asbestos Exposure and Gestational Trophoblastic Disease: A Hypothesis. Cancer Epidemiology Biomarkers & Prevention [online] December, 18(11):2895-2898 [viewed 23 August 2014] Available from: doi:10.1158/1055-9965.EPI-09-0731
  2. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  3. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2010.31.0151
  4. WALKINGTON L, WEBSTER J, HANCOCK BW, EVERARD J, COLEMAN RE. Hyperthyroidism and human chorionic gonadotrophin production in gestational trophoblastic disease Br J Cancer [online] 2011 May 24, 104(11):1665-1669 [viewed 23 August 2014] Available from: doi:10.1038/bjc.2011.139
  5. DULEY L.. Pre-eclampsia and the hypertensive disorders of pregnancy. British Medical Bulletin [online] 2003 December, 67(1):161-176 [viewed 23 August 2014] Available from: doi:10.1093/bmb/ldg005
  6. ALIFRANGIS C., AGARWAL R., SHORT D., FISHER R. A., SEBIRE N. J., HARVEY R., SAVAGE P. M., SECKL M. J.. EMA/CO for High-Risk Gestational Trophoblastic Neoplasia: Good Outcomes With Induction Low-Dose Etoposide-Cisplatin and Genetic Analysis. Journal of Clinical Oncology [online] December, 31(2):280-286 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2012.43.1817
  7. LURAIN JOHN R.. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology [online] 2010 December, 203(6):531-539 [viewed 23 August 2014] Available from: doi:10.1016/j.ajog.2010.06.073
  8. YüRüYEN MEHMET, YILDIZ OZCAN, PAPILA CIGDEM, TUZUNER NUKHET. Gestational choriocarcinoma diagnosed with spontaneous splenic rupture after pregnancy induced by in vitro fertilization: a case report. Array [online] 2009 December [viewed 23 August 2014] Available from: doi:10.1186/1757-1626-2-7518
  9. BALAGOPAL PG, PANDEY MANOJ, CHANDRAMOHAN K, SOMANATHAN THARA, KUMAR ASHWIN. . World J Surg Onc [online] 2003 December [viewed 05 September 2014] Available from: doi:10.1186/1477-7819-1-4
  10. EKANE GREGORY HALLE, TEBEU PIERRE MARIE, OBINCHEMTI THOMAS EGBE, NJAMEN THEOPHILE NANA, NGUEFACK CHARLOTTE TCHENTE, KAMGAING JACQUES TSINGAING, PRISO EUGENE BELLEY. Postpartum hemoperitoneum due to rupture of a blood vessel on a uterine pseudo tumor: a case report. Pan Afr Med J [online] 2013 December [viewed 05 September 2014] Available from: doi:10.11604/pamj.2013.16.57.3363

Differential Diagnoses

Fact Explanation
Normal pregnancy [2] As GTD are commonly follow a pregnancy, this maybe hard to differentiate from a normal pregnancy but a high hCG level may point towards the diagnosis of GTD. [2]
Ovarian choriocarcinoma [1] This is rare either gestational or non gestational in origin. Gestational choriocarcinoma is more common than non gestational choriocarcinoma of the ovary [1]
hCG-secreting germ cell tumors [3] Germ-cell tumors can occur in the ovaries or testes, retroperitoneum, mediastinum or even in the cranium. They also secrete beta hCG causing difficult to differentiate [3]
Hemorrhagic Cystitis (Non infectious) [4] Exposure to toxins, radiation, drugs can cause hemorrhagic cystitis with hematuria and urinary symptoms [4]
Brain tumors, Cerebrovascular accidents [6] Neurological symptoms in a patient with metastatic gestational trophoblastic disease may be difficult to differentiate with a patient with a cerebral tumour or cerebrovascular accident. [6]
Urothelial Tumors of the Renal Pelvis and Ureters, Bladder cancer [5] Transitional epithelial cells lining the urinary tract from renal calyces to ureteral orifice and bladder can undergo malignant transformation. These cancers give rise to hematuria which is painless similarly seen in GTD. [5]
References
  1. CHOI YOUN JIN, CHUN KEUN YOUNG, KIM YONG WOOK, RO DUCK YEONG. Pure nongestational choriocarcinoma of the ovary: a case report. Array [online] 2013 December [viewed 23 August 2014] Available from: doi:10.1186/1477-7819-11-7
  2. CHEN R.-J.. Telomerase activity in gestational trophoblastic disease and placental tissue from early and late human pregnancies. [online] 2002 February, 17(2):463-468 [viewed 23 August 2014] Available from: doi:10.1093/humrep/17.2.463
  3. SCHWABE J., CALAMINUS G., VORHOFF W., ENGELBRECHT V., HAUFFA B. P., GOBEL U.. Sexual precocity and recurrent -human chorionic gonadotropin upsurges preceding the diagnosis of a malignant mediastinal germ-cell tumor in a 9-year-old boy. Annals of Oncology [online] 2002 June, 13(6):975-977 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdf085
  4. MANIKANDAN R, KUMAR S, DORAIRAJAN LN. Hemorrhagic cystitis: A challenge to the urologist Indian J Urol [online] 2010, 26(2):159-166 [viewed 23 August 2014] Available from: doi:10.4103/0970-1591.65380
  5. BELLMUNT J., ORSOLA A., WIEGEL T., GUIX M., DE SANTIS M., KATAJA V.. Bladder cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 22(Supplement 6):vi45-vi49 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdr376
  6. MAY TAYMAA, GOLDSTEIN DONALD P., BERKOWITZ ROSS S.. Current Chemotherapeutic Management of Patients with Gestational Trophoblastic Neoplasia. Chemotherapy Research and Practice [online] 2011 December, 2011:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2011/806256

Investigations - for Diagnosis

Fact Explanation
Serum Beta hCG [1] [2] [3] [4] [5] [6] [7] [8] The levels are very high than in normal pregnancy. [1] [2] [3] [4] [5] [6]
Full blood count [1] [2] [3] [4] [5] [6] This helps to detect anemia secondary to bleeding. [1] [2] [3] [4] [5] [6]
Pelvic ultrasonography [1] [2] [3] [4] [5] [6] [7] [8] This may show persistent molar tissue in the uterus which gives "Snow storm" appearance. [1] [2] [3] [4] [5] [6]
A uterine dilatation and curettage (D&C) and histopathology [1] [2] [3] [4] [5] [6] This may help to determine the histological diagnosis of H-mole whether it's partial, complete, invasive or a choriocarcinoma [1] [2] [3] [4] [5] [6]
References
  1. LURAIN JOHN R.. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology [online] 2010 December, 203(6):531-539 [viewed 23 August 2014] Available from: doi:10.1016/j.ajog.2010.06.073
  2. REID A., HEYWORTH J., DE KLERK N., MUSK A.W.. Asbestos Exposure and Gestational Trophoblastic Disease: A Hypothesis. Cancer Epidemiology Biomarkers & Prevention [online] December, 18(11):2895-2898 [viewed 23 August 2014] Available from: doi:10.1158/1055-9965.EPI-09-0731
  3. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  4. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2010.31.0151
  5. MAY TAYMAA, GOLDSTEIN DONALD P., BERKOWITZ ROSS S.. Current Chemotherapeutic Management of Patients with Gestational Trophoblastic Neoplasia. Chemotherapy Research and Practice [online] 2011 December, 2011:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2011/806256
  6. CAVALIERE A, ERMITO S, DINATALE A, PEDATA R. Management of molar pregnancy J Prenat Med [online] 2009, 3(1):15-17 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094
  7. RANGWALA TASNEEM H., BADAWI FAIZA. A Profile of Cases of Gestational Trophoblastic Neoplasia at a Large Tertiary Centre in Dubai. ISRN Obstetrics and Gynecology [online] 2011 December, 2011:1-5 [viewed 23 August 2014] Available from: doi:10.5402/2011/453190
  8. DHANDA SUNITA, RAMANI SUBHASH, THAKUR MEENKASHI. Gestational Trophoblastic Disease: A Multimodality Imaging Approach with Impact on Diagnosis and Management. Radiology Research and Practice [online] 2014 December, 2014:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2014/842751

Investigations - Fitness for Management

Fact Explanation
Prothrombin time and international normalization ratio [1] This is done to exclude any coagulopathy [1]
Full blood count [1] To exclude anaemia and also counts are done when patient is on chemotherapeutic agents. [1]
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen [1] To assess fitness for anesthesia [1]
References
  1. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 23 August 2014] Available from: doi:10.4103/0970-9185.81824

Investigations - Followup

Fact Explanation
Serum Beta hCG [1] The levels are done in the follow up to assess the response to therapy and to see the recurrence. [1]
Full blood count [2] [4] This is done to assess blood counts while patients are on Methotrexate [2] [4]
High resolution CT scan of the chest [3] [4] High resolution tomography (HRCT) is helpful to diagnose interstitial lung disease secondary to methotrexate. [3] [4]
References
  1. CAVALIERE A, ERMITO S, DINATALE A, PEDATA R. Management of molar pregnancy J Prenat Med [online] 2009, 3(1):15-17 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094
  2. KINDER A. J.. The treatment of inflammatory arthritis with methotrexate in clinical practice: treatment duration and incidence of adverse drug reactions. Rheumatology [online] 2005 January, 44(1):61-66 [viewed 23 August 2014] Available from: doi:10.1093/rheumatology/keh512
  3. DAWSON J. K.. Investigation of the chronic pulmonary effects of low-dose oral methotrexate in patients with rheumatoid arthritis: a prospective study incorporating HRCT scanning and pulmonary function tests. [online] 2002 March, 41(3):262-267 [viewed 23 August 2014] Available from: doi:10.1093/rheumatology/41.3.262
  4. MAY TAYMAA, GOLDSTEIN DONALD P., BERKOWITZ ROSS S.. Current Chemotherapeutic Management of Patients with Gestational Trophoblastic Neoplasia. Chemotherapy Research and Practice [online] 2011 December, 2011:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2011/806256

Investigations - Screening/Staging

Fact Explanation
Chest radiograph [1] [2] [3] [4] [5] [6] Lung is the most frequent site of metastasis therefore to stage the disease this is done. FIGO Staging is done as following. Stage I – Confined to the uterus, Stage II – Limited to the genital structures, Stage III – Lung metastases and Stage IV – Other metastases [8]
CT scan of the chest [1] [2] [3] [4] [5] [6] This is done to detect small metastasis missed in chest x -ray [1] [2] [3] [4] [5] [6]
CT scan of the abdomen and pelvis [1] [2] [3] [4] [5] [6] This is done to stage the disease. Other common sites of metastasis are lower genital tract, brain, liver, kidney, and gastrointestinal tract. [1] [2] [3] [4] [5] [6]
MRI abdomen, pelvis, brain [1] [2] [3] [4] [5] [6] This is done to stage the disease and to detect metastasis at other sites such as lower genital tract, brain, liver, kidney, and gastrointestinal tract. MRI brain helps in detecting cerebral metastasis [1] [2] [3] [4] [5] [6]
Cerebral spinal fluid/plasma hCG ratio [4] [5] [6] Cerebral involvement can elevate this ratio. [4] [5] [6]
18-fluorodeoxyglucose positron emission tomography (FDG-PET) [4] [5] [6] Tumor sites are highly metabolically active and this principle is the basis for this test to detect tumor deposits. [4] [5] [6]
Histopathology and immunohistochemical staining [7] Histology helps to differentiate partial, complete mole, invasive mole and choriocarcinoma. Imunohistochemical staining for p57 may be helpful as well. [7]
Liver enzymes (AST, ALT) [1] [2] [3] [4] [5] [6] May be elevated in the presence of liver metastasis. [1] [2] [3] [4] [5] [6]
References
  1. RANGWALA TASNEEM H., BADAWI FAIZA. A Profile of Cases of Gestational Trophoblastic Neoplasia at a Large Tertiary Centre in Dubai. ISRN Obstetrics and Gynecology [online] 2011 December, 2011:1-5 [viewed 23 August 2014] Available from: doi:10.5402/2011/453190
  2. DHANDA SUNITA, RAMANI SUBHASH, THAKUR MEENKASHI. Gestational Trophoblastic Disease: A Multimodality Imaging Approach with Impact on Diagnosis and Management. Radiology Research and Practice [online] 2014 December, 2014:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2014/842751
  3. LURAIN JOHN R.. Gestational trophoblastic disease I: epidemiology, pathology, clinical presentation and diagnosis of gestational trophoblastic disease, and management of hydatidiform mole. American Journal of Obstetrics and Gynecology [online] 2010 December, 203(6):531-539 [viewed 23 August 2014] Available from: doi:10.1016/j.ajog.2010.06.073
  4. CAVALIERE A, ERMITO S, DINATALE A, PEDATA R. Management of molar pregnancy J Prenat Med [online] 2009, 3(1):15-17 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094
  5. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  6. MAY TAYMAA, GOLDSTEIN DONALD P., BERKOWITZ ROSS S.. Current Chemotherapeutic Management of Patients with Gestational Trophoblastic Neoplasia. Chemotherapy Research and Practice [online] 2011 December, 2011:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2011/806256
  7. KIPP B. R., KETTERLING R. P., OBERG T. N., COUSIN M. A., PLAGGE A. M., WIKTOR A. E., IHRKE J. M., MEYERS C. H., MORICE W. G., HALLING K. C., CLAYTON A. C.. Comparison of Fluorescence In Situ Hybridization, p57 Immunostaining, Flow Cytometry, and Digital Image Analysis for Diagnosing Molar and Nonmolar Products of Conception. American Journal of Clinical Pathology [online] December, 133(2):196-204 [viewed 23 August 2014] Available from: doi:10.1309/AJCPV7BRDUCX0WAQ
  8. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 05 September 2014] Available from: doi:10.1200/JCO.2010.31.0151

Management - General Measures

Fact Explanation
Patient education and counseling [1] [2] [3] [4] Patient should be properly educated regarding the disease, the nature, the available treatment options, importance of follow up and the prognosis. Counseling plays such an important role, especially regarding next pregnancy and the possibility of recurrence. A partial mole should be followed up up to 6 months and a complete mole up to 1 year. [1] [2] [3] [4]
Contraception [1] [2] [3] [4] [5] Patient should be educated to avoid pregnancy because this may cause diagnostic confusion with high hCG. Barrier method is the preferred method of contraception. Combined oral contraceptive pills cause proliferation of trophoblastic tissue. intrauterine contraceptive devices, DMPA should be better avoided as these can also cause irregular bleeding hence diagnostic confusion. [1] [2] [3] [4] [5]
Careful followup [1] [2] [3] [4] Patient should be carefully followed up with hCG levels. A partial mole should be followed up up to 6 months and a complete mole up to 1 year. [1] [2] [3] [4]
References
  1. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2010.31.0151
  2. RANGWALA TASNEEM H., BADAWI FAIZA. A Profile of Cases of Gestational Trophoblastic Neoplasia at a Large Tertiary Centre in Dubai. ISRN Obstetrics and Gynecology [online] 2011 December, 2011:1-5 [viewed 23 August 2014] Available from: doi:10.5402/2011/453190
  3. CAVALIERE A, ERMITO S, DINATALE A, PEDATA R. Management of molar pregnancy J Prenat Med [online] 2009, 3(1):15-17 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094
  4. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  5. PALMER J. R., DRISCOLL S. G., ROSENBERG L., BERKOWITZ R. S., LURAIN J. R., SOPER J., TWIGGS L. B., GERSHENSON D. M., KOHORN E. I., BERMAN M., SHAPIRO S., RAO R. S.. Oral Contraceptive Use and Risk of Gestational Trophoblastic Tumors. JNCI Journal of the National Cancer Institute [online] 1999 April, 91(7):635-640 [viewed 23 August 2014] Available from: doi:10.1093/jnci/91.7.635

Management - Specific Treatments

Fact Explanation
Chemotherapy [1] [2] [3] [5] [6] Treatment decisions may be determined by FIGO prognostic score. Patients FIGO prognostic score of ≤6 respond well to single-agent chemotherapy with either methotrexate or actinomycin-D. 7 or higher are treated with a combination of chemotherapy known as EMA-CO regimen consisting etoposide, methotrexate, actinomycin D, cyclophosphamide and vincristine. [1] [2] [3] [5] [6]
Suction curettage [2] [3] [4] [5] When patients have fertility wishes, suction curettage is the preferred method. Oxytocic agents and prostaglandin analogues are used only when there is massive hemorrhage after evacuation. 250 IU anti-D immunoglobulin is given for Rh negative women after surgical evacuation [2] [3] [4] [5]
Surgical management [2] [3] [4] [5] Uncontrolled vaginal bleeding and no fertility wishes direct towards a hysterectomy. A hemorrhage is also controlled by ligation of uterine or hypogastric artery or embolization. Hepatic artery embolization to control hemorrhage from hepatic metastases is also done. [2] [3] [4] [5]
Radiotherapy for metastatic disease [7] Cerebral metastasis and liver metastasis may benefit from radiotherapy [7]
References
  1. MAY TAYMAA, GOLDSTEIN DONALD P., BERKOWITZ ROSS S.. Current Chemotherapeutic Management of Patients with Gestational Trophoblastic Neoplasia. Chemotherapy Research and Practice [online] 2011 December, 2011:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2011/806256
  2. CAVALIERE A, ERMITO S, DINATALE A, PEDATA R. Management of molar pregnancy J Prenat Med [online] 2009, 3(1):15-17 [viewed 23 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279094
  3. AGHAJANIAN C.. Treatment of Low-Risk Gestational Trophoblastic Neoplasia. Journal of Clinical Oncology [online] December, 29(7):786-788 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2010.31.0151
  4. DHANDA SUNITA, RAMANI SUBHASH, THAKUR MEENKASHI. Gestational Trophoblastic Disease: A Multimodality Imaging Approach with Impact on Diagnosis and Management. Radiology Research and Practice [online] 2014 December, 2014:1-12 [viewed 23 August 2014] Available from: doi:10.1155/2014/842751
  5. SECKL M. J., SEBIRE N. J., FISHER R. A., GOLFIER F., MASSUGER L., SESSA C.. Gestational trophoblastic disease: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 24(suppl 6):vi39-vi50 [viewed 23 August 2014] Available from: doi:10.1093/annonc/mdt345
  6. ALIFRANGIS C., AGARWAL R., SHORT D., FISHER R. A., SEBIRE N. J., HARVEY R., SAVAGE P. M., SECKL M. J.. EMA/CO for High-Risk Gestational Trophoblastic Neoplasia: Good Outcomes With Induction Low-Dose Etoposide-Cisplatin and Genetic Analysis. Journal of Clinical Oncology [online] December, 31(2):280-286 [viewed 23 August 2014] Available from: doi:10.1200/JCO.2012.43.1817
  7. HANNA R. K., SOPER J. T.. The Role of Surgery and Radiation Therapy in the Management of Gestational Trophoblastic Disease. The Oncologist [online] December, 15(6):593-600 [viewed 05 September 2014] Available from: doi:10.1634/theoncologist.2010-0065